When we first thought about commissioning this series of inclusion health policy papers, it was difficult to know where to start. Working within Pathway we are daily confronted by evidence of widespread system and service failure (and we summarised much of it in our 2024 Homeless and Inclusion Health Barometer). These multiple failures mean that people experiencing homelessness, destitution or other forms of profound social exclusion are regularly let down by the NHS, one of our national institutions we might all expect would be there for us when we are most in need.
Too often it feels like a system designed to shut them out, while the foundations we all need to keep us healthy, such as a safe, secure home, have been kicked out from under them. The ‘three shifts’ that Wes Streeting wants to see seem far out of reach for this population.
In the end, we settled on four main components of the NHS, and two key enablers that are at the heart of driving positive change. While each of our authors focuses on their specific area and shares specific proposals for change, perhaps predictably a set of common themes have also emerged.
The authors share a good deal of hope and optimism about the possibilities for change in a reformed NHS. Our experts, many of whom combine frontline roles with research and advocacy, are proposing actionable policy proposals to shift the dial on inclusion health. Some of them are deceptively simple. Sam Dorney-Smith’s plan for proper recording of housing status in NHS data is a straightforward change that can unlock, for the first time, proper accountability in the NHS for healthcare for patients facing extreme health inequalities. Others, such as Dr Jenny Drife’s call for more assertive outreach services for people facing mental health crises, will be harder to achieve, but are well within the grasp of a Government serious about preventing further ill health and tackling homelessness.
Some of these changes might seem paradoxical and reinforce the need to look beyond mainstream solutions. Dr Chris Sargeant describes how shifting care from hospital to the community for people facing homelessness in fact relies on driving up the quality of their hospital stays, with multi-disciplinary hospital teams working to achieve lasting change by properly connecting patients to primary care and housing services in the community. The fact that these shifts might look a little different for this population should not be a deterrent to making them happen. In fact, understanding how best to flex future reforms to meet the complex needs of this group will benefit a system that increasingly needs to grapple with growing complexity in the population as a whole.
Our authors also share understandable frustration. They describe the exhaustion that comes from constantly working against the grain: “examples of great initiatives have been led by champions fighting against systems that do not incentivise or support the work needed to shift the dial on outcomes for people in inclusion health populations”, says Dr. Aaminah Verity. Particular ire is reserved for the ‘pilot-itis’ that is the sad hallmark of services for people in inclusion health groups. The message from our authors is clear – the evidence is there, in the NICE guidelines and elsewhere. The task now is implementation, moving away from penny-packet, temporarily funded initiatives, and implementing meaningful, long-term reform.
Turning the tide on deep seated health inequalities cannot be done by the healthcare system alone. The full array of social determinants of health are at play, with housing the most acute. This is why in her paper Gill Leng calls for deeper integration between health and housing at local system level. And while local action is needed, her proposals to enable this are in the gift of central Government and don’t require lots of extra funding – pooling funding streams, a simple check on how health policy affects people who are vulnerably housed. All of our authors are emphatic in their call for investment in safe and stable housing, with Crisis’s call for 90,000 social homes being the key action Government needs to take to make this a reality.
As well as the reforms our authors are calling for, it will be vital for Government to get the accountability and outcome metrics right for people facing extreme health inequalities. Last week’s NHS planning guidance continued the tradition of asymmetry in its treatment of mainstream priorities relative to inequalities. Targets and outcome measures were reserved for high-volume priorities, while inequalities were couched in soft encouragement. The Government says that this is in support of local freedoms and flexibilities. Eyes are now on the NHS 10 Year Plan for clarity on how a new operating model can ensure that those who face the poorest outcomes receive the service they need. Pathway’s goal to end discharges from hospital to the street, or Gill Taylor’s ambition to end premature deaths from people in homeless or other inclusion health populations would both be good tests of a system working in concert for people who need it most.
A Government facing a tough Spending Review and many competing priorities may ask why they should focus on this group of people. First, there is good evidence that investing in and implementing the right reforms will actually save money. The NHS spends millions of pounds already on people in this population. The opportunity now is to spend more wisely, supporting prevention and long-term health. Second, Dr Aaminah Verity offers a policy rationale when she points out the similarities between people in inclusion health groups and the growing numbers of complex, multi-morbid and frail people in the general population. In designing services for inclusion health groups, she says, “the healthcare system can not only address extreme health inequalities but better address complex, socially determined health needs for all.” But beyond this is the moral case, made by Gill Taylor when she says there are 1,474 reasons to act. This is the number of people who died while homeless last year, a shocking and desperate end for so many people who had already lost so much in life. Better health and social care, underpinned by a long-term housing plan, can prevent so much of this.
Wes Streeting told NHS leaders back in November, “there’ll be no more turning a blind eye to failure.” We hope he is true to his word and will make tackling the failures the cause the most extreme health inequalities his top priority.